Welcome

Welcome to the POZ/AIDSmeds Community Forums, a round-the-clock discussion area for people with HIV/AIDS, their friends/family/caregivers, and
others concerned about HIV/AIDS. Click on the links below to browse our various forums; scroll down for a glance at the most recent posts; or join in the
conversation yourself by registering on the left side of this page.

Privacy Warning: Please realize that these forums are open to all, and are fully searchable via Google and other search engines. If you are HIV positive
and disclose this in our forums, then it is almost the same thing as telling the whole world (or at least the World Wide Web). If this concerns you, then do not use a
username or avatar that are self-identifying in any way. We do not allow the deletion of anything you post in these forums, so think before you post.

The information shared in these forums, by moderators and members, is designed to complement, not replace, the relationship between an individual and his/her own
physician.

All members of these forums are, by default, not considered to be licensed medical providers. If otherwise, users must clearly define themselves as such.

Forums members must behave at all times with respect and honesty. Posting guidelines, including time-out and banning policies, have been established by the moderators
of these forums. Click here for “Am I Infected?” posting guidelines. Click here for posting guidelines pertaining to all other POZ/AIDSmeds community forums.

We ask all forums members to provide references for health/medical/scientific information they provide, when it is not a personal experience being discussed. Please
provide hyperlinks with full URLs or full citations of published works not available via the Internet. Additionally, all forums members must post information which are
true and correct to their knowledge.

Author
Topic: Superinfection! Is it real and what causes it? (Read 37080 times)

Thanks Rich, for that. I think it might be useful if you could clarify, for us laypeople, the distinction between superinfection, re-infection, and co-infection?

Also, a comment on the statistic often bandied about: that the rate of superinfection in newly infected gay men is 5%.

Jay

Logged

Her finely-touched spirit had still its fine issues, though they were not widely visible. Her full nature, like that river of which Cyrus broke the strength, spent itself in channels which had no great name on the earth. But the effect of her being on those around her was incalculably diffusive: for the growing good of the world is partly dependent on unhistoric acts; and that things are not so ill with you and me as they might have been, is half owing to the number who lived faithfully a hidden life, and rest in unvisited tombs.

I can't comment on the 5% of gay men being infected but I did see something about that in a paper today...although I don't think it went into the statistics.

To clarify the other question..

For this discussion, superinfection and re-infection are the same thing. Let's be clear we are only talking about HIV.

Coinfection would be where you get two distinct viruses at the time of transmission. When I say distinct this could mean infection with a 'wild type' strain and mutant strain of the same clade or two or more different clades. This is distinct to coinfection with HepC and HIV, which is the other time you will read the term co-infection. This relates to coinfection of two distinct types of viruses and would be the correct term for infection of HIV with any other virus at the same time.

HOWEVER, if someone has become infected with two different HIV viruses, that person is said to be 'co-infected with <insert HIV types>'. This would be as a result of superinfection/reinfection

I hope that clarifies..

R

Logged

NB. Any advice about HIV is given in addition to your own medical advice and not intended to replace it. You should never make clinical decisions based on what anyone says on the internet but rather check with your ID doctor first. Discussions from the internet are just that - Discussions. They may give you food for thought, but they should not direct you to do anything but fuel discussion.

Thanks Rich. This is one of the 5% articles I read. This one's by Keith Henry from thebody.com from 2004. I've sen several others on aidsmap etc.

February 9, 2004

Dr. Smith and colleagues presented their experience looking for cases of HIV superinfection in the cohort of HIV-positive patients that they followed after identification of primary infection. The topic of superinfection is important for several reasons. First, it provides important insight into protective anti-HIV immunity. The issue is whether the innate anti-HIV immunity that evolves in an infected person can prevent infection with a second strain of HIV. That is important clinically since a few anecdotal reports have suggested that superinfection can lead to more rapid deterioration of a patient's immune status. It is also important from the public health perspective with implications for the potential efficacy of a vaccine to prevent infection.

Several definitions need to be clarified. Co-infection describes when someone is initially infected with two strains, while with superinfection a patient is infected with one strain and then with another strain. Superinfection has been observed in some chimpanzee models and has been inferred from recombination analysis but is still a rarely documented clinical event.

Smith reported the results of a retrospective analysis of trials of primary infection in a cohort of 78 men who have sex with men (MSM) during their first six months living with HIV infection. These men were not yet on antiretroviral therapy. Samples of virus underwent pol gene sequencing and if isolates didn't cluster then env sequencing was done.

Three cases of possible superinfection with another type B virus were identified and then confirmed by clonal sequencing of env and pol sequences. All three men had a change in the reverse transcriptase sequence that could impact drug sensitivity. When those three patients were evaluated six months after acquiring the second strain, a negative impact on the CD4 count and RNA level was seen.

The 5% rate of superinfection is about the same rate as at risk infection initial infection in high-risk populations in the U.S. The interpretation was that there was no protection afforded by the initial HIV infection against superinfection. Dr. Smith said that the lab approach may underestimate the true rate of superinfection due to sensitivity issues with the assays used. It seems to me that a group of MSM with fairly recent HIV infection may represent a group with a higher than average risk for acquiring additional HIV so that extrapolation to the general MSM population may overestimate the overall risk. Whatever the actual rate is, these data add to the literature about superinfection and support enhanced emphasis on harm reduction counseling. A question from the audience highlighted that of the three cases reported, two had been previously reported in other reports. Clearly the topic is of interest and more studies looking at the rate and impact of superinfection are needed.

Her finely-touched spirit had still its fine issues, though they were not widely visible. Her full nature, like that river of which Cyrus broke the strength, spent itself in channels which had no great name on the earth. But the effect of her being on those around her was incalculably diffusive: for the growing good of the world is partly dependent on unhistoric acts; and that things are not so ill with you and me as they might have been, is half owing to the number who lived faithfully a hidden life, and rest in unvisited tombs.

typically... a single viral strain become dominant... and that is most often the wild type... So, me having the wild type with no resistance (but a couple mutations) having sex with someone who does have resistant virus is not likely to transmit that resistance to me. hence, very little worrying over this issue for me.

My theory on this is that those who have become 'superinfected' have been extreme drug users/bingers and were repeatedly exposed to multiple strains in a very immune weakened condition, which may have let those other strains 'gain hold'.

I believe that somebody who is relatively healthy has no worry about reinfection or superifection due to natural body mechanics.

Of course, that 'theory' presents a scenario of only having limited partners in good health, which is what I do....or at least hope to do again someday.

Behavior such as extreme drugging (weakinging the immune system) and whoring (fucking tons of guys) could just get you there.. maybe.

But even that seems such a remote and far-fetched scenario that it just seem ridiculous to worry about.

I will be willing to test this theory with several members here to be sure... contact me via pm. It's all for 'science' after all.

Sadly Darwin evolution suggests that your theory that the virus will mutate into something more benign is sadly unlikely. If there is drug selection pressure and the virus can gain an advantage by recombination it will.

I'm not sure I follow Dingo's "dormant" idea but it wouldn't typically be would occur. Superinfection does occur and having the virus already only limits your chances of getting it again - it doesn't eliminate it.

While I am convinced it can happen, the only relevant argument here is how frequently it would happen and who is at risk. The reports I have read do study people who have unprotected sex a lot and have multiple exposures. The reason they are most studied is that they are more likely to find a result of superinfection in those people given the number of sexual engagements. I guess my question is if you don't care about superinfection and have unprotected sex with a number of people, this exposes you to a similar rate to the people studied in those papers.

I guess the bottom line is that given the number of studies it is hard to get values and trends from such a low number of people. Papers often talk only of a single case study - because there are few assays designed to monitor superinfection rapidly in a large number of people. This technology is coming online and I am sure someone like the NIH will do such a study in large numbers...if they haven't already. Then we should get a look at the magnitude of the problem. Until that point (and it might have been done already) we are only basing theory on extrapolation of data from a small n-number of people. Sort of like trying to quantify how many people will die of mad cow disease based on a few people who have it...

Rich

Logged

NB. Any advice about HIV is given in addition to your own medical advice and not intended to replace it. You should never make clinical decisions based on what anyone says on the internet but rather check with your ID doctor first. Discussions from the internet are just that - Discussions. They may give you food for thought, but they should not direct you to do anything but fuel discussion.

1) Why is there such a strong link between the term superinfection/reinfection and drug resistance? Isn't it more likely that reinfection occurs with wild type viruses? I say that because aren't most drug resistant strains not as fit as wild-type strains? Therefore wouldn't a drug resistant strain have a harder time establishing itself (assuming the host isn't on the meds that this strain is resistant to)?

Basically, people (HIV positive folks) now assume that superinfection means drug resistance....but that's not the case.

2) Do the medical community call reinfections for other diseases superinfections? I've heard the term reinfection used before. I have never heard of superinfection, until it was discussed in the context of HIV.

3) The 5% figure quoted in that study. If they only studied men who were recently infected, could that potentially overstate the risk? I always thought your immune system was most at risk for reinfection during primary infections because your body was still building up its immune defenses to HIV, and that once you were in the chronic phase it was more difficult to acquire a new strain because your body offerred more protection.

Why is superinfection more linked with resistance? Because that's the danger. It does happen with non-mutant viruses too, but it is more talked about with resistance because superinfection allows recombination - giving HIV the chance to shuffle it's genome with another HIV from another person.

R

Logged

NB. Any advice about HIV is given in addition to your own medical advice and not intended to replace it. You should never make clinical decisions based on what anyone says on the internet but rather check with your ID doctor first. Discussions from the internet are just that - Discussions. They may give you food for thought, but they should not direct you to do anything but fuel discussion.

There are serious methodological problems with proving second infections are second infections. For example, a review of all the research on superinfection in 2005 by Julia Marcus found no reported cases of superinfection in which a source partner for the second virus was identified. A person with a dual infection at baseline may express the 2 viruses one after the other, thus appearing to be superinfected. It is also very hard to show that a second strain that pops up was not present at baseline.

As part of the San Francisco arm of the Acute Infection and Early Disease Research Program, dual/sequential/super infection was looked for. The estimated incidence was 2.1%, which is comparable to the 5% reported by Smith and colleagues. In the SF work, out of 192 person-years of follow-up, 4 cases of possible superinfection were found. Problems about showing superinfection rather than dual infection at baseline noted above mean these remain possible either way. The San Francisco Positive Partners study found no possible cases of superinfection after 233 person-years of follow up. Etc etc including a similar finding for a cohort of IV drug users....

We don't know a lot about this. For one we don't actually know that it happens at all, we just surmise based on highly suggestive evidence. We don't know if it happens, why it happens. We don't know if it happens, whether combo protects against superinfection, including resistant type. We don't know why it appears to happen in the first 3 years of being HIV+ and not at all, or 1 in 1 million cases, later on. Etc etc. We don't know why in some cases it appears to affect disease progression and others not.

All we really know is that a small number of apparent superinfection cases have occurred during the first three years of infection, and studies of people with long term infection have found no evidence of superinfection, and that there are about 2 dozen cases of resistance etc compromising treatment that are attributed possibly to superinfection.

I think I'm gonna stop worrying about this. Basically it seems like no-one knows and there a ton of variables so it would only be a waste of my mental energy.

I'm with you on this.

I have enough to worry about, like that time my mom somehow forgot to tell me about my cousin who was taking antibiotics for TB when we went to visit them... and CD4s, and viral load, and my job, and meds, and all that crap... I don't think I'm going to let such a wildly hypothetical case bother me too much.

It's under "who scooped the litterbox" but above "dammit, we don't have HBO."

Sometimes I think it would be better to never have sex again.....this seems like all too much to think about.

Is sex really worth it anymore? It seems like everyone has something to lose....

It makes me sad that I'm probably never really going to enjoy sex again. There is just too much that can possibly happen as a result of it......so what's the point?

Do you normally use condoms? If you do then you really shouldn't be worrying about this. If, like me, you don't then it's food for thought definetely, but you shouldn't let things like this ruin your sex life.

Yes, I use condoms for anal sex....it's oral sex that I worry about. Yes, I know they say that it's not that risky...if there are no open sores/cuts/etc in the mouth or on the genitals...but I still wonder. I mean, it's friggin microscopic....

I just don't want to pass it on or worsen my already bad situation. And I'd rather not have sex at all then use condoms for oral sex....

Yes, I use condoms for anal sex....it's oral sex that I worry about. Yes, I know they say that it's not that risky...if there are no open sores/cuts/etc in the mouth or on the genitals...but I still wonder. I mean, it's friggin microscopic....

I just don't want to pass it on or worsen my already bad situation. And I'd rather not have sex at all then use condoms for oral sex....

maybe I'm just paranoid........

I've givenn a lot of oral sex with this damn bug over the past couple years... and I've yet to catch something else.

The risk is still there... but it's pretty minimal. You're so much more likely to get something from unprotected intercourse.

Yeah I mean, I have NEVER come across a gay guy who uses condoms for oral sex. Honestly, I'm not sure they even exist. The chances of getting HIV from oral sex is extremely small in itself, the chances of superinfection would be absolutely miniscule. If you worried about the theoretical risk for everything then you honestly would never do anything. Seriously, I really don't believe it's even an issue.

Let's be clear about a few things. The term "Superinfection" was not invented by the media. It is a virological term that has been incorrectly picked up by the media and has been banded around interchangeably with "Super virus". Superinfection, as newt said, means "on top of". Superinfection is where you repeatedly infect the same cell with more virus - be it the same strain or a different one. It's been around for longer than HIV. Sadly, with our ever hysterical media, this has been blown out of all proportion.

I have read papers in the journal of Virology that state cases of superinfection. However, they were from sex workers that have had frequent exposures. They know that the person has been infected with two different viruses as they came from different clades.

So what is the danger of superinfection? A single cell infected by two different HIV strains will allow viral recombination within that cell to produce something that wasn't around before. Superinfection has been blamed for hybrid HIV viruses - although I haven't read the data to support that. I guess the danger would be that if you were resistant to NNRTIs and were infected with a PI resistant virus they would recombine to make a virus resistant to both and deliver unwanted multidrug resistance. Indeed, you could argue that if you had mutations that gave low resistance to a drug and were superinfected with a virus containing mutations that augmented this mutation you could get drug resistance where it wasn't seen before.

However, what really is the risk? It's hard to quantify as the numbers of actual superinfections remains low - and often come from drug users or people who frequently have unprotected sex and are at multiple risks. What chance therefore of being superinfected and the two viruses conspiring to create a virus that is now resistant to something you were taking. Probably very low. However, there are documented cases of HIV superinfection and the relevance of this and frequency has to be determined. Only then can we quantify the risk to people getting multidrug resistance.

To answer Cliff's question, if you get superinfected with another virus does that mean you will die in 6 months. Probably not. Let's be clear about something. HIV mutates every day in millions of people. If it could come up with a combination that killed all people rapidly I believe it would have done so by now. Viruses produced from superinfection might be bad for a particular person based on their immune response to that HIV but it doesn't translate that this virus is a rapid killer.

I hope that clears up a few myths..

Rich

Hey Rich,

Don't know you, but thank you for bringing a voice of reason to this subject. When I started it my aim wasn't to panic anyone or convince anyone to have unprotected sex.

I think you and several others have contributed greatly to the overall understanding for me and many others.

Also, for those willing to share personal history so honestly I greatly appreciate your views. I'd like to ask those few who have been judgemental or critical what their motivations are? What's that saying? Get off your cross, someone could use the wood. You're only cutting off your own foot and won't learn anything. How does it benefit you to continue to belittle and judge someone else? Furthermore, those types of comments only prevent others from stepping up and sharing honestly and candidly!

This subject is one important to a lot of people. And, frankly due to the lack of thorough scientific studies I'd like to hear personal stories as well. Now, I wonder if anyone will be willing to share at all.

Yeah I mean, I have NEVER come across a gay guy who uses condoms for oral sex. Honestly, I'm not sure they even exist. The chances of getting HIV from oral sex is extremely small in itself, the chances of superinfection would be absolutely miniscule. If you worried about the theoretical risk for everything then you honestly would never do anything. Seriously, I really don't believe it's even an issue.

Exactly, I'd worry about the risk of super infection from oral sex they way I worry about the risk of getting hit by a meteorite.

They're both risks... but not risks that are going to stop me from living my life in anyway.

Yeah I mean, I have NEVER come across a gay guy who uses condoms for oral sex. Honestly, I'm not sure they even exist. The chances of getting HIV from oral sex is extremely small in itself, the chances of superinfection would be absolutely miniscule. If you worried about the theoretical risk for everything then you honestly would never do anything. Seriously, I really don't believe it's even an issue.

Ohh i did once. He wanted to wear a condom while I sucked on it.

Logged

Floating through the void in the caress of two giant pink lobsters named Esmerelda and Keith.

Was he poz and you were neg? Was he trying to protect you from any cooties he had? Or were you poz and he was neg/unknown status?

The irrationality of this is something I've been boggled by for ages. I can just about understand the guy sucking to want the guy who's getting sucked to have a condom on -- so that there's no exposure to pre-cum and cum (for the blowjob-giver). But the other way around -- when the guy getting sucked wants to suit up because he's afraid of the fellator's saliva -- just shows how often irrational fear trumps transmission lessons.

Oh well. I've politely declined when this situation came up (so to speak) once.

Logged

Her finely-touched spirit had still its fine issues, though they were not widely visible. Her full nature, like that river of which Cyrus broke the strength, spent itself in channels which had no great name on the earth. But the effect of her being on those around her was incalculably diffusive: for the growing good of the world is partly dependent on unhistoric acts; and that things are not so ill with you and me as they might have been, is half owing to the number who lived faithfully a hidden life, and rest in unvisited tombs.

You aren't going to get HIV from oral sex...so lets stop that right here.

I don't want to get into the debate about 3 years being a window for superinfection, because there isn't enough data yet to suggest that's true. I believe that superinfection occurs, but to what level I do not know. I don't buy the argument that an HIV strain remains dormant for 3 years during an infection to rear it's head and take over. It's not the simplest explanation for the data. The magnitude of superinfection is under debate but it is probably low and you could think of several reasons for that.. a few spring to mind. However, unprotected sex puts someone at risk for other STDs and that is something that is going to complicate an HIV infection for no reason.

R

Logged

NB. Any advice about HIV is given in addition to your own medical advice and not intended to replace it. You should never make clinical decisions based on what anyone says on the internet but rather check with your ID doctor first. Discussions from the internet are just that - Discussions. They may give you food for thought, but they should not direct you to do anything but fuel discussion.

typically... a single viral strain become dominant... and that is most often the wild type... So, me having the wild type with no resistance (but a couple mutations) having sex with someone who does have resistant virus is not likely to transmit that resistance to me. hence, very little worrying over this issue for me.

My theory on this is that those who have become 'superinfected' have been extreme drug users/bingers and were repeatedly exposed to multiple strains in a very immune weakened condition, which may have let those other strains 'gain hold'.

I believe that somebody who is relatively healthy has no worry about reinfection or superifection due to natural body mechanics.

Of course, that 'theory' presents a scenario of only having limited partners in good health, which is what I do....or at least hope to do again someday.

Behavior such as extreme drugging (weakinging the immune system) and whoring (fucking tons of guys) could just get you there.. maybe.

But even that seems such a remote and far-fetched scenario that it just seem ridiculous to worry about.

I will be willing to test this theory with several members here to be sure... contact me via pm. It's all for 'science' after all.

Hey, I'm a giver.

Totally onboard with ya on this one. I got my mutation or "super infection" the sustiva class does not work for me, BEFORE i started meds! Since starting meds no OTHER strains and guess what, I am still a little on the slutty side and guess what I typically only sleep with POZ dudes and I like to give and get bareback!!! Do we discuss mutations or meds or shit, no. Here is my theory, the WORST thing in the world that can happen to me as a result of unprotected sex (which we ALL admit feels MUCH better) has already happened. So, whatever will be, will be! I still believe that once stable and on meds with a healthy immune system the chance of reinfection with a different strain is simply not a PROVEN statistical FACT!

I agree that the chances of superinfection are lower on meds. However, the British Government said that transmission of BSE to humans was not possible once because there was no data to suggest that it occurred. There is now, and 175 people had to die to prove it. I guess it comes to personal choice and belief. The similarity to the BSE crisis is that in that case and in this there is a danger that it could happen. How you deal with that danger is up to the individual. Me, I ate beef. Moooo

R

« Last Edit: February 14, 2007, 11:23:28 PM by HIVworker »

Logged

NB. Any advice about HIV is given in addition to your own medical advice and not intended to replace it. You should never make clinical decisions based on what anyone says on the internet but rather check with your ID doctor first. Discussions from the internet are just that - Discussions. They may give you food for thought, but they should not direct you to do anything but fuel discussion.

Forgive me if I repeat anyone else's thunder but my understanding of this supposed superinfection is that it was the virus passed from someone that has been on HAART and maybe resistant to most classes thats why its hard to treat.

The old HIV support group i was a part of I'm Maryland beleives its not so much a superinfection but moreless a highly resistant strain of HIV that had been mutated by the person in NYC who had been on Crystal and slept with hundreds of men without condoms

You aren't going to get HIV from oral sex...so lets stop that right here.

I'm SO tired of seeing this absolute dismissal of oral sex as a transmission route. It is the ONLY viable transmission route in my case and I have come across enough guys in a similar situation to know I'm not alone.

I realise the assumption often will be that I'm somehow in denial about unprotected anal sex. I'm not. I have barebacked in the past, but it is sufficiently long ago, and with enough negative HIV tests in between, that I know it is not the transmission route in my case.

Do I think oral sex is low risk? Absolutely - I was simply very unlucky. And the small risk that there is associated with oral sex is entirely on the part of the person giving the blowjob. Am I now using condoms for oral sex? No, I never have and I'd still rather politely decline altogether.

I am guilty of poor posting, so let me put what I stated about oral sex again.

You are not going to get HIV superinfection from oral sex.

Meaning the probability of getting HIV from oral sex is low. The probability of superinfection is also low. The cumulative probability of both events is so low it isn't worth thinking of.

I didn't want to type out the above qualification, but it appears I had to anyhow.

Apologies for not being clear in the first place,

Rich

Logged

NB. Any advice about HIV is given in addition to your own medical advice and not intended to replace it. You should never make clinical decisions based on what anyone says on the internet but rather check with your ID doctor first. Discussions from the internet are just that - Discussions. They may give you food for thought, but they should not direct you to do anything but fuel discussion.